While my most recent H&P is obviously longer and encompasses a more complete ROS, PE, and SOAP, I think that my narrative language is more confident. This is a double-edged sword though as I tend to over-editorialized and include unnecessary details. I am still figuring out which abbreviations are acceptable to include from other classes and teaching materials.

I sense that my history-taking has become more systematic while also cultivating a more seemingly-organic, conversational affect with my patients.

In writing my HPI, I am able to construct a more clearly structured summary in my mind’s eye before I put pen to paper. This is helpful in both structuring my interview as well as my documentation.

In terms of performing the physical exam, I think that my comfort and confidence in talking to patients and laying hands on another person is my strongest asset. I would attribute this to my background in EMS and the bouquet of traumas, pathologies, and bodily fluids that I’ve already encountered. I have also become more mentally and physically organized in my head-to-toe approach to examining the human body. On the other hand, my overconfidence can lead to details being overlooked and having to go back and re-examen certain body systems.

Moving forward, I must be diligent in maintaining a detail-oriented mentality with a confident and approachable demeanor. With more repetition and a stronger background in pathophysiology and clinical medicine, I anticipate that I will grow exponentially as a clinician during my upcoming clinical rotations.

PD2 NYPQ ED H&P with SOAP Note

Please see the above link for my most recent H&P from my last visit to NYPHQ’s Emergency Dept. on April 9, 2019.

When determining whether or not to prescribed any controlled substance to a patient, the PA has a moral obligation to evaluate their actions as they relate to the principles of beneficence while also recognizing and respecting their patient’s autonomy. Despite the low-risk nature of Viagra and the apparent stability of Mr. S’s health, I would rather not write the prescription with only the current amount of information available. I’d like to call attention to a few key issues I take with this situation, as they pertain to beneficence and autonomy, that ultimately steer me away from satisfying Mr. S’s request.

In our previous reading, Yeo, Moorhouse, and Khan state that, “Good intentions constitute an important aspect of beneficence, but so too does the ability to produce good outcomes.” In a clinical setting, this refers to both the PA’s desire and ability to effect a positive outcome for their patients. According to Yeo, it is equally important to discuss and determine what constitutes as positive outcome. The onus is on the PA to respectfully elicit and explore any discrepancies between the patient’s values, priorities, and concerns versus the PA’s and to work towards a set of treatment options that will satisfy both parties’ values. Assuming that Mr. S has been honest in denying any erectile dysfunction, and that he is seeking a Viagra prescription based on the advice of a gym buddy and to feel like “more of a man,” I’m concerned that Viagra will not address Mr. S’s underlying issues. As a PA, the desire to provide Mr. S with an immediately positive outcome is outweighed by the possibility of latent negative consequences, such as a chemical or psychological dependency on Viagra for sexual arousal, which would be a stark violation of beneficence towards my patient.

Autonomy, synonymous with liberty, is agency over one’s own thoughts and actions, and I have no desire to impinge on Mr. S’s sense of autonomy. Yeo, Moorhouse, and Dalziel make the distinction between autonomy as free action, effective deliberation, authenticity, and moral reflection. Mr. S is a cognizant adult, not operating under any obvious duress or impairment. I trust that he has a basic sense of morality and self-awareness, but I am still concerned when he says that he’d like to feel like “more of a man.” This makes me question the extent to which he has reflected on the subject of his sexuality and masculinity. I’d like to ask him, in an emotionally neutral and non-judgmental manner, what “more of a man” means to him. I would not dismiss whatever response he offers, and I would encourage him to feel free to explore and verbalize his own feelings about masculinity. I would also gain a better sense of Mr. S’s authenticity and moral reflection. On the other hand, maybe there are no significant underlying emotional, social, or psychological issues at play, and Mr. S admits that it is a physical issue. In that case I would feel much better about prescribing the Viagra, but at present Mr. S has denied erectile dysfunction and I am weary of moving forward with the new medications for this patient. Just as patients have the ability to request or refuse treatment, I must also exercise my autonomy as a practitioner by withholding treatments or prescriptions until I am satisfied that I have done my due diligence with regards my patient’s physical, emotional, and psychological condition.

Beneficence and autonomy are two principles that might appear to be at odds with one another at times, such as patients like Mr. S desiring to exercise their autonomy in a way that conflicts with my sense of long-term beneficence. It is usually possible to resolve such discrepancies through further discussion with patients while demonstrating empathy and a desire to understand their perspective. This will elicit a more thorough and honest history, contextualized by the patient’s personal concerns and moral values. In turn, the patient will be more receptive to medical advice that they are given, advice that they might have initially disagreed with or dismissed altogether. This kind of rapport and trust between clinician and patient will often facilitate the best foreseeable outcomes for the patient that are in accord with the principles of beneficence and both parties’ senses of autonomy.

WORKS CITED

Yeo, M., Moorhouse, A., and Dalziel, J. “Autonomy”. Concepts and Cases in Nursing Ethics. pp. 91-97, 103-109, and 130-135.

Yeo, M., Moorhouse, A., and Khan, P. “Beneficence”. Concepts and Cases in Nursing Ethics. 3rd Ed. Broadview Press. pp. 103-117 and 135-139.

Follow like to video here.

H&P Scan

While I am still getting familiar with the Blackboard interface, I am pretty comfortable with WordPress, so my feelings are more than a little biased towards favoring the CUNY Commons site. I am still figuring out how to post artifacts on the Blackboard ePortfolio in a way that will appear as I hope it will and can be easily shared. I think that I will become better accustomed to both as time goes on though and we post more artifacts as a class.

I’m not thrilled about having to come up with a new profile and username/password to remember for CUNY Commons, but I am happy with how the page looks right off the bat. The WordPress template makes for easy visualization of what I am working with and the editing tools and interface are relatively intuitive. At this point, I’m still a little unclear as to how much content from our homework and other upcoming projects will be going onto both ePortfolios. I’m also not exactly sure who the entire intended audience is outside of our classmates and faculty, so I’m not sure exactly how I should be wording my profile page and general presentation.

(Above image from Medcomics by Jorge Muniz, PA-C)

Ms. B is a 56-year-old woman who comes to your office because her skin and eyes have been yellow for the past 2 weeks.

Ms. B also tells you she has dark urine, light-colored stools, anorexia, and fatigue. She has no nausea, vomiting, abdominal pain, or fever. Ms. B’s physical exam shows scleral icterus and jaundice as well as hepatomegaly, with her liver edge palpable 7 cm below the costal margin. The liver extends across the midline, and the spleen tip is palpable. There is no abdominal tenderness or distention. There is no peripheral edema, and the rest of her exam is normal.

Given the pivotal historical points (dark urine and light colored stools) and the physical exam findings of jaundice, hepatomegaly, and splenomegaly, you are confident that Ms. B has hyperbilirubinemia and suspect that it will be primarily conjugated. You obtain the following initial tests: total bilirubin, 13 mg/dL; direct bilirubin, 9.6 mg/dL; AST, 250 units/L; ALT, 113 units/L; alkaline phosphatase, 503 units/L; albumin, 2.8 g/dL; prothrombin time (PT), 15.4 s (control 11.1 s); WBC = 22,000 cells/mcL with 80% PMNs, 16% lymphocytes, and 4% monocytes. The platelet count is normal.

Ms. B had a blood transfusion in Latvia in 1996. She has no history of injection drug use, tattoos, or smoking, but she has consumed between 2 glasses and 1 bottle of wine daily for years. Her past medical history is notable only for Helicobacter pylori–positive gastric and duodenal ulcers 6 years ago, treated with eradication therapy. She is taking no medications.

Ms. B’s transaminases are consistent with, but not diagnostic of, ALD. An imaging study is necessary not to rule in ALD but rather to exclude alternative diagnoses. As discussed in Chapter 3, Abdominal Pain, ultrasound is the best first test to look for stones in the gallbladder, although the sensitivity is less for common bile duct stones. However, in this patient, pancreatic cancer or other malignancies are more likely causes of extrabiliary obstruction than stones; therefore, an abdominal CT scan or MRCP would be a better first test. Tests for hepatitis are necessary in all patients with liver disease and are especially important in Ms. B because of her history of a blood transfusion.

Ms. B has an abdominal CT scan, which shows an enlarged, nodular liver, moderate ascites, and a normal pancreas. Her ANA, hepatitis A IgM antibody, HBsAg hepatitis B IgM core antibody, and hepatitis C antibody are all negative.

SOAP Note:

S: Ms. B is 56 y/o female patient c/o “yellow skin and eyes” x 2 weeks. Reports darkened urine, clay-colored stool, anorexia and fatigue. Denies nausea, vomiting, abdominal pain, or fever. Denies history of IDU, tattoos, or tobacco use. Admits to average of 4 glasses of wine daily for years. Reports history of H. Pylori-positive gastric and duodenal ulcers 6 years ago and 1 blood transfusion in 1996.

O: Physical exam reveals scleral icterus, jaundice, and hepatomegaly. Liver edge palpable 7 cm below costal margin. Spleen palpable. No ABD tenderness or distention. No peripheral edema. Rest of physical exam unremarkable.

A: Patient is experiencing conjugated hyperbilirubinemia as evidenced by jaundiced appearance and dark urine. Clay colored stool indicates that there is either an intrahepatic or extrahepatic disruption in the conduction of bile to the duodenum. Suspected Alcoholic Liver Disease (ALD) or hepatitis.

P: Order Aspartate Aminotransferase Test (AST) to test for blood AST levels and abdominal CT scan to assess for extrabiliary obstructions. Order compulsory full Hepatitis panel secondary to history of blood transfusion. Educate Mrs. B about the long-term effects of alcohol consumption and liver disease as well as serious risks associated with drinking. Develop plan with Ms. B to reduce her alcohol consumption and schedule follow-up in 2 weeks to check on progress of her condition and confirm reduced alcohol consumption.

Write-Up Topic: A Heuristic Approach to Developing a Differential Diagnosis of Hyperbilirubinemia

A patient that presents with jaundice has elevated bilirubin in their bloodstream. The first question that must be answered is, “Which kind of bilirubin is the main culprit?”

There are two major categories of hyperbilirubinemia: conjugated and unconjugated. This is tested for as either more than 50% “direct” or “indirect” in our blood, respectively. All bilirubin, as it’s been freshly released from lysed RBCs, originally circulates as unconjugated until it is processed by the liver into conjugated bilirubin. The conjugated bilirubin is converted into bile, carried to the duodenum via the biliary tract, and excreted in our stool, giving our stool it’s characteristic medium to dark brown color. Some bilirubin will interact with the microflora of our intestinal tract and be reabsorbed into our blood. Most of that reabsorbed conjugated bilirubin will be reabsorbed by the liver and turned back into bile, but some will be filtered by the kidneys. Alternatively, if conjugated bilirubin is not being converted into bile, or the bile is not making its way to the duodenum, it will become backed-up in the liver and ultimately back into the bloodstream and ending up in the kidneys. If there is enough conjugated bilirubin in circulation, it will eventually become concentrated in the urine enough to darken the color from amber to light brown.

Why am I spending so much time on urine and stool?

Jaundice with normal urine and normal stool indicates that liver function and bile conduction are intact, but that there is still a massive influx of circulating, unconjugated bilirubin secondary to major hemolytic events.

Jaundice with dark urine and light stool indicates that conjugation by the liver is intact, but for some reason it is not making its way to the intestines as bile. This could be due to occlusion, internal or external, of the biliary tract or something internal to the liver that is prohibiting the full production or conduction of bile such that that conjugated bilirubin is backing-up into the bloodstream.

These are a few examples of the ways in which we can start to build a reliable foundation upon which to build our differential diagnosis just from an effective HPI and PE. We will still send out for serum bilirubin testing to determine the percentage of conjugated versus unconjugated bilirubin, but we can already get a sense of which pertinent negatives need to be ruled out and which kinds of tests should be ordered without wasting time or resources.